02030123 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMIT NO.
19650 AUBURN DR JUST WATER HEATERS INC 02030123
OWNER'S NAME: APPLICgTION SYR DATE
LISA FENG 1764 NATIONAL AVE 03/21/2002
'ONE: (510) 293-9901 SANITARY NO. CONTROL NO.
G 0 ZOARC]IITECT/ENGINEER BUILDING PCRMIT INFO
kC BLDG ELECT PLUMB MECH
i d I=
N 6 LICENSED CONTRACTOR'S DECLARATION Job Description
jZ_� Ihercby aflirm owl mn licemal under pnrvisimns of Chapter (mmmene'mg REPLACE WATER HEATER.
�C witlts¢,imn 700f1)of Division3nfthe Business anJ Prnlessions Code.and my liceme
ix < 6ce s lass ode cath (40 GALLON GAS)
z�< License Class Lie.N r
So a u Dae Contractor
t O ARCHITECT'S DECLARATION
Y I underhand nay plans shill he nscd as indhe records
1 S p O License)Professional
OWNER-BUILDER DECLARATION
t� I hereby affirm that 1 am exempt from the Contractors License Law for the
a following reams.(Section 7031.5,Business and Professions Code:Any city or minty
{F C which requires a permit to,mmilp c(,alae,improve,demolish,or tepau any,hu,nme
Badh islcaumegal.nna,to the provision of
for Commences
ommcLicense Law
(Chapter
(M
— twtneislian.,mpnt,u:mtnmepmhhmn.nnnecnn.mcer.ue=n.eLaw(enayer9 Sq. Ft.,FloorArea. , Valuation
(romtncncing with sution'l000)of Uivisimn 3 mf le Business au]P ofeasions Code) a x a .k 4
or that he is exempt therefrom and the basis for the alleged dreard.n.Any violation
-or ccann 70315 by nnyapplicm Int a permit subjects the applicant to a civil Penalty
mrnilatre man five eandreddnnnrs 5500) APN Number Occupancy Type
❑1,as ox net of the property,or any employees with rages as their sole compensation,
will do The work,and the structure is net intended or offered for sale(Sec.7011, -
Business and Professions Code:The Cmarrear's License Law does net apply 10 as 506 — GAS TESRequired Inspections
owner mr prnpeny Who I ilds or improves dercon,and who does sash work himself
mr Thom 1,his own employeesp oukd that each imprwernn;arc not intended or 507 - FINAL PLUMBING
offered for sale.if,however,the building be improvement is ed saithjpp one year of
completion,me weer-builder will hem the burden nfprovins.that hedtU build or
improve for purpose ofsale.).
°I,as owner of the prnpeny m,excluxivdy mnbacting int li4'e�i RJ con s ,
constmct the project(Sec.7044,Business and Posters r Godo?: he Contfffaaa ml's
License Law does not apply man owner of progeny wh guilds nr int �`
and rant,nitronc
s for projects with a con }Jigcnsed p to I
Contractor's License Low.
❑I am exempt under Sec. ,B clubt
Owner Dee G�
WORKER'S COMPENSATION DECLARATION /
1 hereby affirm under penahy of perjury one n!the following declarations:
1 one and will maintain a Cerifcate of Coastal to eel Linsure for WB,kere /
\. Compensation, as provided for by Section 37110 of the Littler Code, for the 1
Performance of the work for which this Permit is itemed.
❑I lee and will maintain Worker's Compensation Insurance,as required by Section
3700 of the Labor Code,for the performance of the work for which this permit is
sued.My Worker's Compensation Insurance carrier and Policy Wollner are:
Caller. it Policy No.:
CERTIFICATION OF EXEMPTION FROM WORKERS' -
COMPENSATION INSURANCE
(Thi s section need not he completed if the Permit is for one handed dollars
($100)or IessJ
1 certify that m the performance mf the work for which this Permit is issued.1
shall not employ any person n any manner so as to become subject is the Workers'Contpomsation Law s.I'Calipaida.Dam
Applicant
NOTICE TO APPLICANT:If efer making this Certificate of Exemption.you should
z 0 become subject o the Workers Compensation provisions of the Labor Calc,you must
fonhwim comply with such provisions or this permit shall M deemed revoked .1
CONSTRUCTION LENDING AGENCY
a 7 1 hereby affirm that there ise construction lending agency for the performance
of the xark far which this gene is issued(Sec.3097,Civ.C.)
Q Larder's Name - -
Under',Address
V I certify that I hove rtad lis application and see mat me above immermtinn is
W •e.t correct.]agree to comply dwilh he ell city and cmomy ordinances and stale Jews relating
Q V to libovegcnnioned n,andhemtiyomeamin representatives of this city to ether upon Y`4'-Gnf.(�I/ VV •\.•
�..W the anmvememienm propend for inspection p hmrrme..
W es,judgments,
m,costwl,and expensesy and
keep i hm may
roan way aCupertino against
U h liabilities,judgments,costs and expenses whor may in any way accI against,said
I;) ,7, City inconse UNDERSTANDS
of the grantingD I permit. ^
SOURCE
UNDERSTANDS ANO WILL COMPLY WITH ALL NON-POINT
souecEREcuLAnons. Issued by: Date
Signature ofA,licanUComranor - Date Re-roofs
' IIAZARDOUSMATERIALSDISCLOSURIi
Will the applicant or fumes binding ocopma sabre or handle hazardous ma¢nal Type of Roofas defined by the Cupertino Municipal Code.Chapter 9.12.and the Health end Safety
Code,Section 25532(x)?
°Yes I °N.- All roofs shallbe.inspected prior to any.roofing material being installed.
AdKWill meaptlilaatnrfmmrtbuildingarnpanteeequlpeeatordeviceswhltlt If a roof is installed-without first obtainingan inspection, I agree to remove
emit hazardous eircon Warrants as defied by the Bay Area Air Quality M......con
P g
)isWcR all new materials for inspection. Applicant understands and will comply with
°Yes 0N all non-point source regulations.
<-� I have read the hazardous materials requirements under Chapter 6,95 of the
Coliform.Health&Safety Code,Semens 25505,25.533 and 25534.1 undemmnd that
if the building does not currently have a tenant.that it is my responsibility to notify the
mrcupactof me requmen
irets xmpri
Lich must be et or a issuance of x Cmifcae of
txa9p.ney. - Signature of Applicant Date _
Dwn=r p�aammdaed:geht Dae All roof coverings to be Class `B"or better
-. - OFFICE